Source: Robert E. Sallis, MD. Kaiser Permanente, Fontana, California, USA
The wrist is a complex joint made up of 8 carpal bones and their numerous articulations and ligaments. Overlying the wrist are the tendons and muscles of the hand and fingers. The hand is made up of 5 metacarpal bones, and the tendons that run to the hand overlie these bones. Finally, the fingers consist of 14 phalanges with their articulations held together by collateral ligaments and volar plates. Common mechanisms of both acute and chronic wrist injury include impact, weight bearing (which can occur in gymnastics), twisting, and throwing. Osteoarthritis of the hand commonly affects distal interphalangeal (DIP) and proximal interphalangeal (PIP) joints, while rheumatoid arthritis (RA) is seen in the metacarpophalangeal (MCP) and PIP joints.
It is important to compare the injured wrist or hand to the uninvolved side. Key aspects of the wrist and hand exam include inspection, palpation for tenderness or deformity, testing the range of motion (ROM) and strength, neurovascular assessment, ligaments and tendon testing, and the special tests.
Insect both hands and wrists comparing between the sides, and look for the following:
- Swelling or masses in the joints or soft tissue, commonly seen with arthritis or ganglion cysts.
- Redness or warmth, which may suggest inflammation or infection.
- Atrophy of muscles, which can be seen with severe nerve injury or entrapment.
- Wrist palpation
Ask the patient to bend the elbow; then, palpate the wrist for tenderness and deformity using the tips of your index and middle fingers (see the structures of the wrist in List 1).
Perform palpation of structures on the dorsal side with the patient's palm facing down and the structures on the palmar (volar) side with the palm facing up.
- Hand palpation
Palpate the hand, looking for tenderness or deformity.
- Palpate the following structures on the dorsal side of the hand with the patient's elbow bent and the palm facing down.
- Extensor tendons: Feel for the rope-like structures extending to the proximal end of the distal phalanx of each finger across the dorsum of the hand. Tenderness here may suggest tendonitis.
- Metacarpals and phalanges: Palpate each bony segment for tenderness, which may suggest a fracture.
- Palpate the following structures on the volar side of the hand with the patient's elbow bent and the palm facing up.
- Flexor tendons (flexor digitorum profundus and superficialis): Feel for rope-like structures across the palm of the hand, extending to the base of the middle phalanx (superficialis) and base of the distal phalanx (profundus) of each finger. Tenderness here may suggest tendonitis, and popping over the MCP area with finger flexion suggests a trigger finger.
- Thenar eminence: Palpate the muscle mass on the radial side of the palm located proximally to the base of the thumb. Atrophy here can be seen with median neuropathy (carpal tunnel syndrome).
- Hypothenar eminence: Palpate the smaller muscle mass on the ulnar side of the palm, located just beyond the distal wrist crease. Atrophy here can be seen with ulnar neuropathy.
- Lastly, palpate the joints:
- MCP, PIP, and DIP joints: Palpate in each finger and note any tenderness and/or swelling that may be seen with arthritis.
- Collateral ligaments: Palpate along either side of each PIP and MCP joint. Tenderness may indicate a strain or tear of the ligament (seen in a jammed finger).
- Palpate the following structures on the dorsal side of the hand with the patient's elbow bent and the palm facing down.
List 1. Structures of the wrist to be examined by palpation
- Radial dorsal side:
B.Scaphoid (anatomic snuff box)
C. 1st CMC joint and base of 1st MC (arthritis)
D.Abductor pollicis longus (APL) and extensor pollicis brevis (EPB) tendons (De Quervain's tendonitis)
- Central dorsal side
A.Lunate (Kienbock's disease or scapholunate dissociation) and capitate
B.Extensor carpi radialis longus and brevis (Intersection syndrome where they cross APL and EPB tendons)
C.Ganglion cysts common (may be occult)
- Ulnar dorsal side:
B.Triquetrum and hamate bones
C.Triangular fibrocartilage complex (TFCC)
- Radial volar side:
B.Long finger flexors and palmaris longus
C.Median nerve (carpal tunnel)
- Ulnar volar side:
A.Hook of hamate and pisiform bones
B.Ulnar nerve and artery (Guyon's canal)
3. Range of Motion
Range of motion (ROM) should be assessed first actively and then passively, if needed. Normal motion generally follows the "rule of 90s" in the wrist and fingers. Compare side-to-side, looking for deficits in the ROM.
- Ask the patient to turn the palms directly upward (90° supination) and downward (90o pronation) while keeping the elbows at sides. Normally these motions can be performed without pain.
- With the patient's elbows at the side, ask the patient to press the palms together and point fingers upward; then, ask the patient to press the back of the hands together and point the fingers downward. Normally with hands pressed together, wrists should extend and flex approximately to 90°.
- Ask the patient to make a fist with all fingertips touching the palmar crease. In this position, each MCP and IP joint is flexed to 90°.
- Ask the patient to touch the tip of the thumb to the base of the pinkie.
4. Strength Testing:
Note any pain or weakness while performing the following tests:
- Ask the patient to flex and then extend the wrist while you are resisting the movement. This should be painless.
- Ask the patient to grip your finger and not let you to pull your finger free. This should be painless, and you should not be able to pull your finger free.
- Ask the patient pinch a piece of paper between the thumb and index finger, and again between the thumb and long finger. It should take a significant tug to get the paper free.
5. Motor Exam
Assess motor function of the hand using the following tests:
- Ask the patient to flex and extend the thumb; this checks function of median and radial nerves.
- Ask the patient to "scissor" the fingers together and apart; this checks ulnar nerve function.
- Ask the patient to place the hand on flat surface palm up and raise the thumb against resistance; this checks median nerve function.
- Evaluate the circulation to the hand by palpating for radial and ulnar pulse. Occasionally, the ulnar pulse may not be easily palpable.
- Check capillary refill by applying pressure to the finger pad. Release the pressure and observe for the skin color. Normal skin color should return in 2 seconds.
Evaluate sensations by checking for light touch, pinprick, and 2-point discrimination (7 mm or more on finger pads). Specifically check the following: Tip of thumb (median nerve); Tip of fifth finger (ulnar nerve); dorsum of hand (radial nerve).
8. Ligament and Tendon Testing
It is important to stress the ligaments in injured areas to evaluate for possible rupture. Commonly injured ligaments include:
- Collateral ligaments of the fingers: Assess by applying a varus and valgus stress to the injured joint: stabilize the proximal bone with one hand and push the distal bone in medial (valgus test) and then lateral (varus test) direction. Laxity is indicative of ligament rupture.
- Ulnar collateral ligament of the thumb: Apply abduction stress to the first MCP joint with the thumb both flexed and extended by pushing the distal phalange in lateral direction. Pain with this test suggests a strain of the ligament, while laxity suggests a tear.
- DIP extensor and flexor tendons: Evaluate the extensor and flexor tendons of the fingers by stabilizing the PIP joint with your fingers and asking the patient to both flex and extend the DIP joint. The inability to extend suggests rupture of the extensor tendon (Mallet finger), while the inability to flex suggests rupture of the flexor tendon (Jersey finger)
9. Special Tests
There are several important diagnostic specific tests that are commonly done for evaluation of the wrist and hand. These include:
- Carpal tunnel syndrome tests -these tests will typically aggravate the symptoms associated with Carpal tunnel syndrome (such as tingling, pain and numbness) in the 1st- 3rd fingers.
- Tinel's test: Tap on the volar side of the wrist over the median nerve.
- Phalen's test: Have the patient hold the wrist in a maximally flexed position.
- Carpal tunnel compression test: Press firmly with both thumbs over the carpal tunnel for up to 30 seconds.
- Finkelstein's test
- Have the patient first flex the thumb across the palm, and then flex the other 4 fingers around it.
- Ask the patient to bend the wrist towards the little finger (ulnar deviation). Significant pain with this maneuver is suggestive of De Quervain's tendonitis.
- Arthritis of the thumb (first carpometacarpal joint) tests: Both of these tests will aggravate the pain associated with this condition.
- Watson stress test: Ask the patient to place the hand on the table palm up with all fingers extended, and then push down the thumb towards the table.
- Grind test: Grasp the patient's thumb, and passively rotate the first carpometacarpal joint while simultaneously applying axial pressure on the thumb (pushing it towards trapezium) to load the joint.
Hand and wrist complaints are one of the most common reasons for patient visits to an orthopedic clinic. Common mechanisms of both acute and chronic wrist injury include impact and weight bearing, which can occur in gymnastics, and twisting and throwing, which are part of several sports and outdoor activities.
The wrist is a complex structure made up of eight carpal bones. The palm of the hand is made up of five metacarpal bones, and the fingers and thumb consist of fourteen phalanges. These bones are connected by joints, which are named on the basis of two bones involved, namely the carpometacarpal joints or CMCs, the metacarpophalangealjoints or MCPs and the interphalangeal joints or IPs. Fingers have two interphalangeal joints namely the proximal interphalangeal joint, or PIP and the distal interphalangeal joint or DIP, while the thumb has just one IP joint. In addition, the hand is composed of several muscles, tendons and ligaments, which enable the hand to perform several movements.
Here, we will illustrate a comprehensive and detailed hand and wrist exam that should be performed to reveal fractures or tendonitis. In addition, we'll demonstrate a few specific tests performed to diagnose commonly encountered problems, such as carpal tunnel syndrome, DeQuervain's tendonitis, and arthritis of the thumb.
Let's begin with inspection and palpation. Wash your hands thoroughly before you begin. Start by inspecting both hands and wrists, comparing between sides. Look for swelling or masses in the joints or soft tissue, redness or warmth, and muscle atrophy.
Following inspection, palpate the wrist for tenderness and deformity. First, feel the structures on the dorsal side. The palpable structures in this region are listed in the table below. In the same position, palpate the dorsal side of hand as well. Feel the extensor tendons, which are the rope-like structures extending from the wrist across the hand to the proximal end of the distal phalanx of each finger. Tenderness here may suggest tendon inflammation. Also, palpate the boney segments of the metacarpals and phalanges, where tenderness may suggest a fracture.
Once palpation on the dorsal side is complete, ask the patient to turn their wrist so that you can palpate the structures on the volar side. The palpable structures on the volar wrist are also listed in the table bellow. Following that, palpate the rope-like flexor tendons on the volar side of the hand. These include both flexor digitorum profundus and superficialis tendons. The superficialis tendons extend to the base of the middle phalanx and the profundus tendons extend to the base of the distal phalanx of each finger. Tenderness upon palpation suggests tendonitis and popping over the MCP area that can be felt with finger flexion suggests a trigger finger - a condition in which a tendon inflammation causes a finger lock in flexed position.
Subsequently, palpate the thenar eminence, which is the muscle mass on the radial side of the palm located proximally to the base of the thumb. Atrophy here can be seen with median neuropathy or carpal tunnel syndrome. Then move onto the hypothenar eminence, which is the smaller muscle mass on the ulnar side of the palm, located just beyond the distal wrist crease. Atrophy here can be seen with ulnar neuropathy.
Lastly, palpate the MCP and the IP joints. Be sure to palpate in each finger and note any tenderness or swelling, which may be a sign of arthritis. When palpating the PIP and MCP joints make sure to evaluate the collateral ligaments along the sides of the joints. Tenderness may indicate a strain or tear of the ligament, seen with a jammed finger.
After completing inspection and palpation, move on to testing the range of motion and muscle strength. Throughout this portion, compare side-to-side, looking for deficits, pain or weakness.
Start by holding the patient's forearm, turning the palm directly upward-supination, and downward-pronation. These motions should demonstrate a 90° range without any pain. Next, instruct the patient to press their palms together while pointing their fingers upward to check for wrist extension. Then ask them to press the back of their hands together and point the fingers downward to check for wrist flexion. Again, range for both these movements is about 90°. Instruct the patient to lay the palm flat with fingers together and then make a fist with all of their fingertips facing the palmar crease. The MCP and IP joints should be flexed to 90°. Finally, have the patient to touch the tip of their thumb to the base of their pinky finger. This tests thumb opposition. They should be able to do it without any discomfort.
To begin the strength testing, ask the patient to flex and then extend their wrist while you resist the movement. Normally, the patient should not experience any pain. Next, instruct the patient to grip your finger and not let it go as you attempt to pull it free. This process should be painless and you should not be able to pull your finger free. Lastly, ask the patient to pinch a piece of paper between their thumb and index finger. Then, attempt to pull the paper; it should take a significant tug to get the paper free. Repeat the process with the patient holding the paper between the thumb and middle finger.
Now, let's see how to perform motor, circulation and sensory assessment of the hand and wrist region.
Begin the motor function exams by instructing the patient to flex and extend their thumb, which evaluates the functions of the median and radial nerves. Next, assess the ulnar nerve function by instructing the patient to scissor their fingers together, and apart. In the last motor test, ask the patient place their hand on a flat surface with their palm up and instruct them to lift their thumb as you apply resistance. This is to evaluate the median nerve functioning.
Subsequently, evaluate the circulation to the hand by feeling the radial and ulnar pulse. Occasionally, the ulnar pulse may not be easily palpable. Also, check capillary refill by applying pressure to the finger pad and then releasing the pressure to observe for change in skin color. Normal skin color should return in about 2-3 seconds.
Evaluate sensory perception by conducting the light touch, pinprick, and 2-point discrimination test using the two ends of an open paper clip. During these exams, specially check the tip of the thumb to assess the median nerve, the tip of the 5th finger to assess the ulnar nerve, and the dorsum of the hand to assess the radial nerve.
Next, evaluate the hand and wrist ligaments and tendons. It is important to stress the ligaments in injured areas to evaluate for possible rupture.
First, assess the collateral ligaments of the fingers. Start by stabilizing the more proximal phalanx with one hand, while with your other hand push the more distal phalanx medially, applying varus stress test, and then laterally, applying valgus stress. Laxity is indicative of ligament rupture, while pain suggests a ligament strain.
Then examine the ulnar collateral ligament of the thumb. With the patient's thumb both flexed and extended, apply abduction stress to the first MCP joint, and then push the distal phalange in the lateral direction. Pain during this maneuver suggests a strain of the ligament, whereas laxity suggests a tear.
Lastly, examine the DIP extensor and flexor tendons of the fingers. To do so, stabilize the PIP joint with your fingers, while having the patient both flex and extend the DIP joint. If the patient is unable to extend the DIP joint, it suggests a rupture of the extensor tendon, known as "Mallet finger". The inability to flex the joint suggests a rupture of the flexor tendon, known as "Jersey finger".
Ultimately, let's see how to perform a few diagnostic confirmatory tests that are performed if specific conditions are suspected.
The first group of special tests is for the Carpal Tunnel Syndrome or CTS. The carpal tunnel is a canal on the volar side of the wrist connecting the forearm to the palm. Several tendons and the median nerve pass through it. The CTS is caused by the compression of the median nerve. Its symptoms include tingling, pain and numbness felt in the region covering the thumb and fingers one through three.
For the first test in this group, called the Tinel's Test, tap your finger on the median nerve located on the volar side and check if the CTS symptoms get worse. Next, conduct the Phalen's Test by asking the patient to hold their wrist in the maximum flexed position, and see if that aggravates the pain. Lastly, using your thumb, firmly compress the area where the patient is experiencing the carpal tunnel symptoms, for up to 30 seconds. Aggravation of pain, tingling or numbness confirms the presence of CTS.
The next special test is to diagnose DeQuervain's tendonitis, which is inflammation affecting the tendons on the thumb side of the wrist. It is called the Finkelstein's Test. Have the patient first flex their thumb across the palm and then flex the fingers around it . Then ask the patient to bend the wrist towards their little finger. Significant pain with this test is suggestive of DeQuervain's tendonitis.
The last two maneuvers that we will discuss are the "arthritis of the thumb tests" involving the first CMC. Both these tests will aggravate the pain associated with this condition.
To conduct the first test called the Watson Stress Test, ask the patient to place the hand on a surface palm up with all of the fingers extended. Now push down on the thumb, and note any pain, tenderness or weakness. To conduct the second and the last test called the Grind Test, grasp the patient's thumb and passively rotate the first CMC joint, while simultaneously applying axial pressure on the thumb to load the joint. Again, note any pain, tenderness or weakness. This concludes the hand and the wrist exam.
You have just watched JoVE's video detailing an all-inclusive hand and wrist exam. In this video, we reviewed the essential aspects of this exam including inspection, palpation, range of motion testing, strength testing, motor, circulation, and sensation assessment, ligament and tendon testing, and a few specific diagnostic maneuvers. As always, thanks for watching!
Applications and Summary
Examination of the wrist and hand is best done following a stepwise approach, with the patient in a sitting position. The exam should begin with inspection, looking for asymmetry between the involved and uninvolved wrist and hand. This should be followed by palpation of key structures to identify tenderness, swelling, or deformity. The next step is assessing ROM, first actively and then against resistance to assess strength. Pain with resisted motion often suggests tendonitis, while weakness may suggest a tear. A neurovascular assessment should next be done by first assessing sensation and motor strength, followed by checking pulses and capillary refill. Finally, the various ligaments should be checked for stability, and various other special tests should be performed depending on the suspected diagnosis.